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J Stroke. 2019 Jan;21(1):69-77. doi: 10.5853/jos.2018.03202. Epub 2019 Jan 31.

Estimation of Acute Infarct Volume with Reference Maps: A Simple Visual Tool for Decision Making in Thrombectomy Cases.

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Korean Brain MRI Data Center, Dongguk University Ilsan Hospital, Dongguk University College of Medicine, Goyang, Korea.
Departments of Radiology and Cancer Systems Imaging, University of Texas M. D. Anderson Cancer Center, Houston, TX, USA.
Department of Neurology, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea.
Department of Neurology, Chonnam National University Hospital, Chonnam National University Medical School, Gwangju, Korea.
Department of Neurology, Yeungnam University Hospital, Yeungnam University College of Medicine, Daegu, Korea.
Department of Neurology, Dong-A University Hospital, Dong-A University College of Medicine, Busan, Korea.
Department of Neurology, Eulji University Hospital, Eulji University, Daejeon, Korea.
Department of Neurology, Inje University Ilsan Paik Hospital, Inje University College of Medicine, Goyang, Korea.
Department of Neurology, Hallym University Sacred Heart Hospital, Hallym University College of Medicine, Anyang, Korea.
Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, Korea.
Department of Neurology, Soonchunhyang University Seoul Hospital, Soonchunhyang University College of Medicine, Seoul, Korea.
Department of Neurology, Seoul Medical Center, Seoul, Korea.
Department of Neurology, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea.



Thrombectomy within 24 hours can improve outcomes in selected patients with a clinical-infarct mismatch. We devised an easy-to-use visual estimation tool that allows infarct volume estimation in centers with limited resources.


We identified 1,031 patients with cardioembolic or large-artery atherosclerosis infarction on diffusion-weighted images (DWIs) obtained before recanalization therapy and within 24 hours of onset, and occlusion of the internal carotid or middle cerebral artery. Acute DWIs were mapped onto a standard template and used to create visual reference maps with known lesion volumes, which were then used in a validation study (with 130 cases) against software estimates of infarct volume.


The DWI reference map chart comprises 144 maps corresponding to 12 different infarct volumes (0.5, 1, 2, 3, 5, 7, 9, 11, 13, 15, 17, and 19 mL) in each of 12 template slices (Montreal Neurological Institute z-axis -15 to 51 mm). Infarct volume in a patient is estimated by selecting a slice with a similar infarct size at the corresponding z-axis level on the reference maps and then adding up over all slices. The method yielded good correlations to software volumetrics and was easily learned by both experienced and junior physicians, with approximately 1 to 2 minutes spent per case. The sensitivity, specificity, and accuracy for detecting threshold infarct volumes (<21, <31, and <51 mL) were very high (all about >90%).


s We developed easy-to-use reference maps that allow prompt and reliable visual estimation of infarct volumes for triaging patients to thrombectomy in acute stroke.


Cerebral infarction; Diffusion magnetic resonance imaging; Infarct volume; Reference standards; Thrombectomy

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